Escolar Documentos
Profissional Documentos
Cultura Documentos
Appl. No.
OR No.
Date :
ATTACH 2X2
Colored Photo with
white background
College of Medicine
PERSONAL INFORMATION
Name:
(Last Name)
(First Name)
(Middle Name)
_ Landline No.:
Date of Birth:
Age:
Email Address:
_ Place of Birth:
Sex: [ ] Male / [ ] Female
Citizenship:
[ ] Divorced
Religion:
[ ] Legally Separated
Occupation:
Mother:
Occupation:
Occupation:
Office Address:
Office Address:
Contact No/s.:
Contact No/s:
Email Address:
Email Address:
Are you a permanent resident of another country? [ ] Yes [ ] No If yes, what country?
Permanent Home Address:
Provincial Address (if any):
Form 1
Guardian (other than Parents):
Occupation:
Address:
Contact no/s.:
Email Address:
College:
Present Address:
Contact No/s:
Character References: Give names and addresses of three persons (not relatives) who have known you and
with whom the Committee on Admission can correspond to. Must include someone who has known you as
student in high school /or college and who has taught/supervised you in class.
a.
b.
c.
EDUCATIONAL INFORMATION
Are you a college graduate of any foreign school? [ ] Yes [ ] No
What was the last school attended?
Degree earned:
Schools Attended:
Primary:
Address:
Intermediate:
Address:
High School:
_ Inclusive years:
_ Inclusive years:
Inclusive years:
Inclusive years:
Address:
College:
_ Inclusive years:
Inclusive years:
Address:
Form 1
[ ] No
[ ] Yes, my father is a UERM Alumnus
Class
College
Graduating with Honors? [ ] Yes [ ] No Please check applicable box, if graduating with Honors:
[ ] Summa Cum Laude [ ] Magna Cum Laude [ ] Cum Laude [ ] Honorable Mention
[ ] Others - pls. specify:
Date taken:
Score obtained:
Form 1
FINANCIAL INFORMATION:
How do you plan to finance your education? Please indicate in percentage (%):
Your own resources:
_ Parents:
Other relatives:
Form 1
]
]
]
]
]
]
]
]
]
]
]
[ ] Accepted
[ ] Deferred
/
/
[ ] Denied
Date
For Colleges of :
Nursing
Allied Rehabilitation Sciences
Medical Technology
H.S./ College General Ave.